Provider Demographics
NPI:1285602722
Name:FARRELL, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FARRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:SUITE 3002
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:740 HIGH ST STE 3002
Practice Address - Street 2:SUITE 3002
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3102
Practice Address - Country:US
Practice Address - Phone:570-321-2820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051520363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q01286Medicare UPIN
Q01286Medicare UPIN